Introduction:
Recently, the British intellectual and journalist, Will Hutton, asked the question: “How do you successfully break a mistaken and destructive intellectual consensus?” It set me off immediately thinking of the cosy social world and the mental processes in which the political, professional and academic elites in Barbados conspire to converge on the same ideas, which are implemented in much the same way, often by the same people – and, no matter which party is in control, they all expect different results.

Two ideas come to mind: the break of the consensus by the attorney general on the silly and ill-advised decision to plant taxpayers’ money in to the Four Seasons project, which he rightly sees as a private investment which should be let to private investors. The other is equally as irresponsible, the decision to build a spanking new Bds$800m hospital in Kingsland. Both ideas are loopy and reveal the poverty of our policy-making, especially when it comes to major capital projects.

First, there is nothing fundamentally wrong with the Queen Elizabeth Hospital, opened to the public in 1963, which competent and firm management cannot sort out. What patients are complaining about are issues such as time-wasting, spending hours before being seen by a doctor in Accidents and Emergencies, of under-productive nurses spending time on the wards talking to each other while surgical patients are in pain and crying out for help, over-paid and arrogant, sometimes even questionably competent, doctors being on the public payroll while spending their time looking after their private patients. The list goes on. So, to the ordinary man and woman in the street, the real problem at the QEH is not the building, although that us falling apart, but what goes on inside the building.

Barbados does need a second general hospital with accident and emergencies facilities, but not the one that has been proposed. What is need is a well-equipped hospital situated in the North-East of the country, so that un emergencies people from St Lucy, St Andrew, St Peter, St Joseph and St John would not have to wait until an ambulance arrived from Bridgetown then to take them to a hospital in town or Kingsland. So strategically, the location is the wrong one.

As to the idea that businesses would develop in the surrounding area, pharmacists, shops, rum shops and so on, this is a nonsense. How many businesses have grown up around the QEH or the old general hospital? One question that ought to be asked is if the new private hospital in St Joseph is contractually obliged to treat accidents and emergencies occurring in the vicinity? If not, what we will see developing is a segregated health service, a hospital for the rich while the poor have to travel to Christ Church or Bridgetown to be treated. In other words, what we have seen destroyed in South Africa and the American Deep South, rich white people going to a well-equipped hospital while poor native Barbadians go to the less well equipped hospital, will be transplanted to our island.

Healthcare as Social Policy:
The first task of any committee or sub-group structuring a healthcare policy must to look at the demographic and geographical needs of the community and to project forward these needs a further twenty or thirty years. In Barbados, the task is much simpler than it is in many other countries. First, Barbados has one of the highest infectivity rates for HIV/Aids for under thirty-year-olds in the world. This will put a number strains on taxpayers and, in particular the health care bill: retroviral drugs, a negative impact on the work force, and the risk of spreading the virus. Then there are the existing and future problems as a result of the lifestyle of the majority of people: alcohol abuse, poor diet, over-us of saturated fats, sugar and salt in meals, lack of exercise, over-dependence on private motor vehicles, etc. All these will lead in time to serious chronic diseases such as diabetes and its secondary problems, cancers, and so on.

A proper well-discussed health policy is more than just a hospital building; in fact, a hospital building is not even the most important part. A good healthcare policy is about prevention, regular exercise, eating well and in small portions, and the use of technology to manage the life-long care of patients. If well thought out, it would also include proper contractual arrangements with doctors, nurses and ancillary staff.

Management:
The QEH has fallen in to the trap that has plagued organisations, both public and private, since the 1960s, but in particular since the expansion of so-called business schools in the 1980s and 90s. There is a belief that to be a good manager one must be armed with an MBA degree, even those with an emphasis in marketing. The net result is that poor generalist managers are often planted on to organisations which depend on specialist skills, which the managers often do not have any knowledge of. Quite often, having these men (and often they are men) in suits walking around the office or factory |(or even hospital) interfering with the day-to-day work of the experts, and trying to instruct them in how to carry out their tasks can lead to resentment.

The way round this for a well-managed hospital is to put the clinicians, in spite of their collective arrogance and silliness, in charge on the basis that it is much easier to train a doctor to be a manager than a generalist manager to be a manager of doctors. Once that reporting line has been clarified, it must also be made clear that nurses and other ancillary are not doctors’ assistants, but professionals in their own right there to provide a service to patients. In many ways, medicine in Barbados is in the 20th century, and not even at the end, as most patients can testify. I remember a few years ago having a terrible pain in my back and went to a St Lucia-born doctor based on the rim of the Garrison. I remember the surgery well because years ago it was occupied by a dentist called Jimmy Smith. The young make doctor prescribed me some pain killers which, at the time, I did not realised were cutting a hole in my stomach. On returning to London (it was either a Sunday or bank holiday) I went to St Mary’s Hospital in Paddington and the first thing the young registrar did was to dump my tablets in the bin and tell me that they were the cause of my pain, that they were too strong. I do not know which doctor was right. All I can say is that the pain subsided after my visit to St Mary’s.  I remember that because a couple weeks ago I met a Barbadian friend who is now a so-called returnee who was in London for a medical check-up. His story was similar to mine.

We were both lucky because we could both get a second opinion, from totally professional and cultural practitioners. But what about those people who would find it prohibitively expensive to do so? Over-prescription, misdiagnosis and general malpractice are concerns all over the world and Barbados is no exception.

But looking ahead, medical science has moved on by leaps and bounds, and so does the delivery of that service. Doctors based on one country can now carry out diagnoses of patients in another, examine X-rays and make prescriptions from ten thousand miles away. Genetic science has moved on to such a level that medicine can be personalised and drugs can be developed for individuals with chronic diseases, rather than giving the same medicines to every Tom, Dick and Harry.

Contracts of Employment:
Contracts of employment should be comprehensive documents which set out all the duties and obligations of employer and employee, including productivity, behaviour, customer service and proper job descriptions, including time keeping, and am enforceable disciplinary code.

Healthcare Economics:
The big economic issues around health care are loss of working days, the development of chronic diseases and their impact on healthcare costs. Apart from lifestyle changes suggested above, the major healthcare costs are long-term and develop because of the misuse of alcohol, sweets and carbonated drinks, and the abuse of the health service by motor insurers through injured drivers, passengers and the general public, all costs that should be passed on to the motor insurers. In fact, instead of any additional taxes going in to the Consolidated Fund, only to be abused by ministers, it should go in to a hypothecated fund to be used exclusively on healthcare. Over the years, however, the biggest portion of the healthcare budget will be spent on care in the community, looking after the elderly, infirmed and mentally ill in their own homes.

Analysis and Conclusion:
In the final analysis, it is care in the community, looking after the ageing community, that will be the source of the big healthcare spend, not another hospital. And with the development of medical science, most Barbadians will not have to leave the comfort of their own sitting rooms to be treated by the leading medical practitioners in the world. Skype is just an example of a conversion, but so are the facilities for more intimate cross-border medical examinations.

The other major short-term problem is the lack of staff discipline and the general ill-treatment of patients. Employee capability is at the centre of performance and productivity. And, Barbadians are no different to other people; it is just that when employed in the public sector they believe that they do not have to exert themselves. This is an abuse of  taxpayers that should be made a serious disciplinary offence, even to the extent of having an all-out battle with the often irresponsible trade unions. (An example of this trade union madness is the claim for a ten per cent pay rise, at a time when the country is insolvent. It is stupidity bordering on madness).

Lazy and apathetic employees should be sacked on the spot, no matter what union representatives say; those that are incapable through lack of training should be provided with that training; and those whose performance is affected through external pressures, such as family problems, should be provided with the welfare support and time-off as necessary.

The public sector must be a model employer.